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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Property ebaljqr4u <br /> OWNER/OPERATOR <br /> Jacinto Perez Cedeno CHECK ifBILUNGADDREss <br /> FACILITY NAME <br /> SITE ADDRESS 12184 Hibbard Rd Lodi 95240 <br /> Street Number I Direction Street Nam city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 12172 Hibbard Rd <br /> Street Number ofteet NAM <br /> CITY STATE ZIP <br /> Lodi Ca 95240 <br /> PHONE#1 ExT• APN# LAND USE APPuCATION# <br /> ( 209)642-3171 063-230-420-000 <br /> PHONE#2 Err. BOS DISTRICT L� LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Chris Trapp CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME orMAiumGADDRESS 4590 Vista Dr. FAX# <br /> ( 1 <br /> CITY Loomis STATE CA zip 95650 NT <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ag&WMVED <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. JUL 2 0 202' <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with E&NA AbbW LINTY <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPLICANT'S SIGNATURE: DATE: 7-20-21 <br /> PROPERTY/&SINESSOWNER❑ OPERATOR MANAGER ❑ OTHERAuTHORmy, AGENT® Agent of the Owner <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY NVIRONMENTHEALTH DEPARTNQENT as soon as it is available and at the same time it is <br /> _jLprovided to me or my representative. I f <br /> TYPE OF SERVICE REQUESTED: N L S REVIEW - Su: �� ,fG;Li I+} ' lInG, A) �e lo"diz S CS ' 9Pu� <br /> COMMENTS: teLeNer) 1tilYoi'Jh eir.:3 or, 00 d1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7 dv d <br /> ASSIGNED TO: bA EMPLOYEE#: DATE: 7 aC) _7 J <br /> Date Service Completed (if already completed): SERVICE CODE: S 3 PI E: �a <br /> Fee Amount. 608,00 Amount Paid b Payment Date LJ <br /> Payment Type LLJ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />